What preoperative lung functioning tests should be done prior to a pulmonary resection?
- ppoFEV1 and ppoDLCO
- if both > 40%, can proceed
- if either < 40%, need cardiopulmonary exercise testing
- > 15mL/kg/min is average risk
- 10-15 is high risk
- <10 is prohibitive risk
What are the surgical principles for resection of NSCLC?
- lobectomy
- at least 10 nodes removed, 3 from mediastinal (N2) and 1 from pulmonary (N1)
Describe a LLLobectomy.
- VATS port placement and chest exploration
- incision IPL and open the posterior meditational pleura
- remove LNs from 7 (at left mainstem), 9, 10 (at pulmonary artery)
- incise and open the anterior mediastinal pleural and remove AP nodes
- isolate and divide the inferior pulmonary vein
- open the interlobar fissure, identify the PA and branches to the upper and lower lobe
- divide superior segmental artery and common basilar trunk
- isolate the lower lobe bronchus, test inflation, divide
- place a chest tube and close
How should you surveil incidentally discovered lung nodules?
low risk patients
< 6mm: no follow up
6-8mm: imaging in 6-12 months
> 8m: CT at 3 months, PET, or biopsy
high risk
< 6mm: imaging in 12 months
6-8mm: imaging in 6-12 months
> 8m: CT at 3 months, PET, or biopsy
Describe the staging workup for lung cancer.
- all patients need CT chest, PET scan, bronchoscopy, and PFTs
- anyone with clinically suspicious nodes, a central tumor, or tumor >3cm should undergo EBUS/VAM
- brain MRI if nodal disease or tumor > 5cm
Who gets neoadjuvant or definitive chemoradiation for lung cancer?
- N0: upfront surgery
- N1 (ipsilateral pulmonary or hilar): neoadjuvant
- N2 (ipsilateral mediastinal or subcarinal): definitive
What paraneoplastic syndromes are associated with lung cancer?
- SIADH with SCLC
- ACTH with SCLC
- PTHrP with NSCLC
What is the recommendation for lung cancer screening?
annual low dose CT chest from 50-80 for anyone with more than 20 pack year history who has smoked in the last 15 years
Describe a mediastinoscopy.
- 2cm incision above the sternal notch
- retract the strap muscles
- bluntly clear the anterior trachea below the sternal notch
- insert scope and advance to the carina and down the left and right mainstem
Which LN stations are accessible by EBUS?
2, 4, 7, 10, 11, 12
Which LN stations are accessible by mediastinoscopy?
2, 4, 7
What should you do if a frozen of a mediastinal node comes back positive?
abort the operation
Describe a LULobectomy.
- thoracic entry
- open the oblique fissure to find the left PA
- divide the segmental arteries to the pico-anterior, posterior, and singular segments
- divide the superior pulmonary vein
- lymphadenectomy of 5, 6, 7, 8, 9, 10, 11
- test clamp of left upper bronchus and division
When is surgical intervention indicated for those with spontaneous pneumothorax?
- secondary spontaneous pneumothorax
- recurrent primary spontaneous pneumothorax
- persistent air leak or incomplete re-expansion
- history of tension pneumothorax
- history of bilateral pneumothorax
- high risk profession
What is the appropriate operation for spontaneous pneumothorax?
- VATS wedge resection of bullous disease (start 5th IC, anterior axillary line)
- mechanical pleurodesis
What are the hallmarks of a complicated pleural effusion?
- size > 1L
- thick pleural rind
- loculations
What is the indication for VATS decortication?
trapped lung/empyema
Describe pulmonary decortication.
- drain all free fluid
- use a kittner to peel up the visceral pleura
- intermittently ventilate to measure progress
- then remove the parietal pleural as well
